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ADENO-TONSILITISADENO-TONSILITIS

Dr. Tolkha Amaruddin, M.Kes., Dr. Tolkha Amaruddin, M.Kes., SpTHTSpTHT

Dr. Tolkha Amaruddin, M.Kes., Dr. Tolkha Amaruddin, M.Kes., SpTHTSpTHT

RSUD SARAS HUSADAPURWOREJO 2008

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ADENOIDADENOID

A triangular shape mass of lympA triangular shape mass of lymphhoid tissue oid tissue located on the posterior aspect of the box like located on the posterior aspect of the box like

nasopharynx (Bailey, 1998)nasopharynx (Bailey, 1998)

TONSILTONSIL

A paired, in general ovoid shaped masses A paired, in general ovoid shaped masses located on the lateral walls of the oropharynx. located on the lateral walls of the oropharynx. (Ba(Baiiley, 1998)ley, 1998)

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Vascularisation - innervation the adenoids: – The pharyngeal branches of the external

carotid artery. – Sensory the glossopharyngeal &

vagus nerves. – Referred pain from the adenoids (as

well as the tonsils) in both the ears and throat.

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Vascularisation and innervationVascularisation and innervation

The tonsils : – ascending pharyngeal– ascending palatine– lingual & facial arteries

The lymphatic drainage superior deep cervical & jugular lymph nodes inflammatory cervical adenitis/abscess in children.

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99Diagram skematis tonsil palatine & komposisi selDiagram skematis tonsil palatine & komposisi sel

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Distribusi kelas-kelas sel T (CD 3+), sel B ( CD 20+), sel T helper (CD4+) dan sel T sitotoksik (CD 8+).

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Bacteria Bacteria Aerobic :Aerobic : Group A beta hemolytic streptococcus, HGroup A beta hemolytic streptococcus, H.. influenza, Sinfluenza, S.. pneumonia, Moraxella pneumonia, Moraxella cattaralis, Scattaralis, S.. aureus, H aureus, H.. parainflueza, parainflueza, Neiseria sp, Mycobacteria spNeiseria sp, Mycobacteria sp

Anaerobic :Anaerobic : Bacteriodes sp, Peptococcus sp, Bacteriodes sp, Peptococcus sp, PeptostrPeptostreeptococcus sp, Actinomycosis sp.ptococcus sp, Actinomycosis sp.

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Virus : Epstein Barr, Adenovirus, Influenza A Virus : Epstein Barr, Adenovirus, Influenza A and B, Herpes simplex,parainfluenzaand B, Herpes simplex,parainfluenza

Others : Mycobacterium (atypical Others : Mycobacterium (atypical nontuberculous)nontuberculous)

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PATOGENESIS OF ADENOTONSILAR DISEASEPATOGENESIS OF ADENOTONSILAR DISEASE

Anatomic location Anatomic location organs of imunity organs of imunity processing infection material processing infection material a a focus of infection / inflamation focus of infection / inflamation loss loss

integrity of the crypt epithelium integrity of the crypt epithelium chronic cryptitis & crypt obstruction chronic cryptitis & crypt obstruction

stasis of crypt debris & persistence stasis of crypt debris & persistence antigen antigen

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CLINICAL CLASSIFICATION OF THE ADENOIDS & CLINICAL CLASSIFICATION OF THE ADENOIDS & TONSILSTONSILS

Adenoids : Adenoids : AAcute adenoiditiscute adenoiditisRecurrent acute adenoiditisRecurrent acute adenoiditisChronic adenoiditisChronic adenoiditis

TonsilsTonsilsAcute tonsilAcute tonsilllitisitisRRecurrent tonsiecurrent tonsilllitislitisCChronic tonsilhronic tonsilllitisitis

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CLINICAL FEATURES ADENOIDCLINICAL FEATURES ADENOID

Symptoms & signs due to hypertrophy :Symptoms & signs due to hypertrophy :1.1. Nasal obstructionNasal obstruction

2.2. MMouth breathingouth breathing

3.3. Difficulty Difficulty in in eatingeating

4.4. Noisy breathing – snoring Noisy breathing – snoring toneless voice toneless voice

5.5. ‘‘AAdenoid facies’denoid facies’

Eustachian obstruction:Eustachian obstruction:

1.1. DeafnessDeafness

2.2. The presence of fluid in the midThe presence of fluid in the middldle eare ear

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Symptom & sign due to inflamationSymptom & sign due to inflamation1.1.Nasal dischargeNasal discharge2.2.Postnasal drip Postnasal drip 3.3.CoughCough4.4.Otitis mediaOtitis media5.5.Rhinitis & sinusitisRhinitis & sinusitis6.6.Cervical adenitisCervical adenitis

Generalized disturbancesGeneralized disturbancesMental dullness, apathy, poor breathing, bad postureMental dullness, apathy, poor breathing, bad posture,,

deafness, deafness, nocturnal enuresisnocturnal enuresis

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DIAGNOSIS ADENOID (Gray, 1992):DIAGNOSIS ADENOID (Gray, 1992):

1. Rhinos copy posterior1. Rhinos copy posterior2. The lateral soft tissue view2. The lateral soft tissue view

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Differential diagnosis adenoidDifferential diagnosis adenoid

1. Other causes of nasal obstruction1. Other causes of nasal obstruction Vasomotor rhinitis, foreign bodies, hypertropied Vasomotor rhinitis, foreign bodies, hypertropied

posterior ends of inferior turbinates, deflected nasal posterior ends of inferior turbinates, deflected nasal septum, congenital choanal atresiaseptum, congenital choanal atresia

2. Orthodontic abnormalities2. Orthodontic abnormalities High arch palates, wedge shaped faces, narrow High arch palates, wedge shaped faces, narrow

upper jaws, crowded teeth.upper jaws, crowded teeth.

3. Thornwaldt’s disease in which there is cystic persistence 3. Thornwaldt’s disease in which there is cystic persistence of the median furrow of the nasopharyngeal tonsilof the median furrow of the nasopharyngeal tonsil

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TREATMENT ADENOIDTREATMENT ADENOID

ConservativeConservative The symptom are not marked:The symptom are not marked:

Non irritan decongestants nasal drop, fresh Non irritan decongestants nasal drop, fresh air, sensible diet, breathing and postural air, sensible diet, breathing and postural exercise. exercise.

Surgical (Adenoidectomy)Surgical (Adenoidectomy)Nasal obstructionNasal obstruction

DeafnessDeafness

ChronicChronic otorhhoeaotorhhoea

RecurrentRecurrent otitis mediaotitis media

SinusitisSinusitis

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INDICATION FOR ADENOIDECTOMYINDICATION FOR ADENOIDECTOMY

Obstruction: Obstruction: – chronic nasal obstruction chronic nasal obstruction – obligate mouth breathingobligate mouth breathing– Sleep apnea and/or sleep disturbances.Sleep apnea and/or sleep disturbances.

InfectionInfection– Adenoid hyperplasis with Adenoid hyperplasis with RRecurrent /chronic ecurrent /chronic

adenoiditisadenoiditis– RRecurrent/chronic otitis media with effusionecurrent/chronic otitis media with effusion– CChronic otitis mediahronic otitis media

NeoplasiaNeoplasia

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CHRONIC TONSILCHRONIC TONSILLLITISITIS

1. Chronic parenchymatous tonsi1. Chronic parenchymatous tonsilllitislitis2. Chronic follicular tonsi2. Chronic follicular tonsilllitislitis

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CHRONIC PARENCHYMATOUS CHRONIC PARENCHYMATOUS TONSILTONSILLLITIS (Gray, 1992)ITIS (Gray, 1992)

More common in children More common in children (between 4 and (between 4 and 15 years)15 years)

A chronic inflammA chronic inflammaatory hypertrophytory hypertrophy

Associated with enlargAssociated with enlargeement of the ment of the nasopharengeal tonsilnasopharengeal tonsil

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CLINICAL FEATURECLINICAL FEATURE

1. Persistent or recurrent sore throat1. Persistent or recurrent sore throatss2. Persistent cervical adenitis2. Persistent cervical adenitis3. Marked tonsillar enlargement3. Marked tonsillar enlargement4. Injected anterior faucial pillars4. Injected anterior faucial pillars5. Irritation cough5. Irritation cough

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TREATMENT :TREATMENT :1. Conservative1. Conservative

Attention to general health and diet Attention to general health and diet

2. Tonsi2. Tonsilllectomylectomy

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CHRONIC FOLLICULAR TONSILCHRONIC FOLLICULAR TONSILLLITISITIS

Most commonly in adultsMost commonly in adultsFollow repeated attacks of acute follicular tonsillitisFollow repeated attacks of acute follicular tonsillitis

Clinical feature :Clinical feature :1.1. Chronic irritation or repeated sore throatChronic irritation or repeated sore throat2. Cervical adenitis2. Cervical adenitis3. Cough3. Cough4. Bad taste and halitosis4. Bad taste and halitosis

Treatment : 1. ConservativeTreatment : 1. Conservative2. Tonsil2. Tonsilllectomyectomy

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I.I. Seven or more episodes of tonsillitis in one Seven or more episodes of tonsillitis in one yearyear

II.II. Five or more episodes of tonsillitis each year Five or more episodes of tonsillitis each year over a period of two yearsover a period of two years

III.III. Three or more episodes of tonsillitis a year for Three or more episodes of tonsillitis a year for a period of three yearsa period of three years

IV.IV. Tonsillitis that recurs despite treatment with Tonsillitis that recurs despite treatment with antibioticsantibiotics

V.V. Airway or swallowing obstruction due swollen Airway or swallowing obstruction due swollen tonsilstonsils

Patient may be candidate for tonsillectomy Patient may be candidate for tonsillectomy if patient meets one of the following criteria:if patient meets one of the following criteria:

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